Published OnlineFirst April 16, 2014; DOI: 10.1158/1055-9965.EPI-14-0016
Cancer Epidemiology, Biomarkers & Prevention
Research Article
Financial Strain and Cancer Risk Behaviors among African Americans Pragati S. Advani1,3, Lorraine R. Reitzel4, Nga T. Nguyen2, Felicia D. Fisher4, Elaine J. Savoy5, Adolfo G. Cuevas6, David W. Wetter1, and Lorna H. McNeill1
Abstract Background: African Americans suffer disproportionately from the adverse consequences of behavioral risk factors for cancer relative to other ethnic groups. Recent studies have assessed how financial strain might uniquely contribute to engagement in modifiable behavioral risk factors for cancer, but not among African Americans. The current study examined associations between financial strain and modifiable cancer risk factors (smoking, at-risk alcohol use, overweight/obesity, insufficient physical activity, inadequate fruit and vegetable intake, and multiple risk factors) among 1,278 African American adults (age, 46.5 12.6 years; 77% female) and explored potential mediators (stress and depressive symptoms) of those associations. Methods: Logistic regression models were used to examine associations between financial strain and cancer risk factors. Analyses were adjusted for age, sex, partner status, income, educational level, and employment status. Analyses involving overweight/obesity status additionally controlled for fruit and vegetable intake and physical activity. Nonparametric bootstrapping procedures were used to assess mediation. Results: Greater financial strain was associated with greater odds of insufficient physical activity (P < 0.003) and smoking (P ¼ 0.005) and was positively associated with the total number of cancer risk factors (P < 0.0001). There was a significant indirect effect of both stress and depressive symptoms on the relations of financial strain with physical inactivity and multiple risk factors, respectively. Conclusions: Future interventions aimed at reducing cancer disparities should focus on African Americans experiencing higher financial strain while addressing their stress and depressive symptoms. Impact: Longitudinal studies are needed to assess the temporal and causal relations between financial strain and modifiable behavioral cancer risk factors among African Americans. Cancer Epidemiol Biomarkers Prev; 23(6); 967–75. 2014 AACR.
Introduction Cancer is a major public health problem in the United States (1). Although statistics indicate an approximate 20% decline in cancer death rates by the year 2009 from their peak in 1991 (1), considerable disparities still exist in terms of people benefiting from this falling trend. For instance, overall cancer incidence and death rates are higher among African American men than white men for every cancer site (1). Several factors are known to con-
Authors' Affiliations: Departments of 1Health Disparities Research and 2 Biostatistics, The University of Texas MD Anderson Cancer Center; 3 Department of Health Promotion and Behavioral Sciences, The University of Texas School of Public Health; 4Department of Educational Psychology, College of Education and 5Department of Psychology, College of Liberal Arts and Social Sciences, The University of Houston, Houston, Texas; and 6 Department of Psychology, College of Liberal Arts & Sciences, The Portland State University, Portland, Oregon Corresponding Author: Lorraine R. Reitzel, Health Program, Department of Educational Psychology, College of Education, University of Houston, 491 Farish Hall, Houston, TX 77204-5029. Phone: 713-743-6679; Fax: 713743-4996; E-mail: [email protected] doi: 10.1158/1055-9965.EPI-14-0016 2014 American Association for Cancer Research.
tribute toward an increased risk of cancer incidence and associated mortality among African American adults, including smoking, at-risk use of alcohol, being overweight or obese, insufficient physical activity, and inadequate fruit and vegetable intake (1–4). For example, African Americans tend to have higher prevalence of obesity and overweight-related diseases as compared with other racial/ethnic groups (5, 6). Unhealthy dietary habits and lower rates of physical activity have also been cited as contributing to their higher burden of chronic diseases relative to whites (6, 7). In addition, African American smokers are more susceptible to cancer than white smokers, and experience more difficulty quitting smoking (8, 9). Because reducing prevalence of these behavioral cancer risk factors among African Americans is an essential strategy to reduce overall cancer-related health disparities, research focused on better understanding of their specific determinants is needed. Socioeconomic status (SES) is a widely acknowledged social determinant of health and health-related behaviors. Markers of SES include an individual’s education, occupation, and income, which affect health insurance status and access to health services (2, 10, 11). Literature suggests
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Published OnlineFirst April 16, 2014; DOI: 10.1158/1055-9965.EPI-14-0016
Advani et al.
that individuals with lower SES experience worse health outcomes compared with those with higher SES (12, 13). Moreover, racial/ethnic disparities for major cancer sites, including colorectal, breast, and prostate, are largest in the lowest SES groups (14). Lower SES is also associated with a higher prevalence of several modifiable risk factors for cancer, including smoking (15), being overweight/obese (15, 16), lower rates of physical activity (17), and intake of unhealthy diet (15). Unfortunately, African Americans often tend to fall in the lower SES group, predisposing them to an increased risk of worse health outcomes relative to other ethnic groups (18). Recently, research on social determinants of health has gone beyond traditional indicators of SES to consider how more nuanced socioeconomic factors might affect health and health behaviors. One factor of interest is financial strain. Financial strain, also known as income inadequacy, represents an individual’s unfavorable subjective perception of their income to needs ratio (19), and although perhaps most relevant to those of lower SES can be applicable to individuals across the income spectrum. Literature suggests that financial strain is considered a better predictor of mortality than other SES indicators, particularly among African Americans (20). Financial strain is tied to increased unmet health needs and thus increased mortality among older African American adults (20). Likewise, financial strain has been linked to several modifiable cancer risk factors such as higher smoking rates (21–25), lower cessation rates (26), at-risk use of alcohol (22, 23, 25, 27, 28), obesity (29), and unhealthy dietary habits (25). However, limited studies have focused on these associations specifically in the context of the African American population. Furthermore, studies have shown that there are multiple pathways by which an individual’s financial status affects health behaviors (12). Financial strain is associated with psychosocial factors such as higher stress (22, 30) and depressive symptoms (30–34). On the other hand, stress and depression have been causally associated with unhealthy behaviors (35). These relations are also consistent with theoretical models suggesting that lower financial status might engender higher perceived stress and depressive symptoms, which contribute to unhealthy behaviors (12, 36). However, no studies to our knowledge have addressed potential indirect effects of stress and/or depressive symptoms on the association between financial strain and several cancer risk factors among a large sample of African American adults. The purpose of the current study was to examine the unique association of financial strain with several modifiable behavioral cancer risk factors (i.e., smoking, at-risk use of alcohol, being overweight/obese, insufficient physical activity and inadequate intake of fruits and vegetables) in a large sample of church-going African American adults. Because more than 50% of African American adults attend church on a weekly basis (37), and because church settings offer an acceptable and sustainable infrastructure for the delivery of interventions to affect
968
Cancer Epidemiol Biomarkers Prev; 23(6) June 2014
modifiable behavioral cancer risk factors (e.g., 38, 39), studies among African American church-goers are of particular interest. An exploratory aim of the current study was to assess whether significant associations between financial strain and cancer risk behaviors were attributable to stress and/or depressive symptoms. On the basis of the previous literature in this area, we hypothesized that greater financial strain would be associated with higher odds of engagement in behavioral cancer risk factors, and that stress and depressive symptoms would yield significant indirect effects in these associations.
Materials and Methods Participants and procedures Data were from the second year of a longitudinal cohort study focused on elucidating factors associated with cancer risk among African Americans. This was the first year that financial strain items were administered. Participants comprised a convenience sample recruited from a large church in Houston, Texas. Recruitment was accomplished through printed and televised media within the church and in-person solicitation. Individuals were eligible to participate if they were 18 years of age or older, resided in the Houston area, had a functional telephone number, and attended church. Participants (N ¼ 1,501) completed a computerized survey at the church during the first year of data collection, and were contacted a year later to participate for a second time. In total, 1,375 participants (91.6% of the original cohort) participated in the second year of data collection. Participants were compensated with a $30 gift card following the survey procedures. Only participants with complete data on the measures described below (N ¼ 1,278; 85.1% of the original cohort) were included in the current study. Data were collected between January and August 2010. Measures Sociodemographics. Sociodemographics included age, sex, partner status (married/living with partner or single/widowed/divorced), total annual household income (
Cancer Epidemiology, Biomarkers & Prevention
Research Article
Financial Strain and Cancer Risk Behaviors among African Americans Pragati S. Advani1,3, Lorraine R. Reitzel4, Nga T. Nguyen2, Felicia D. Fisher4, Elaine J. Savoy5, Adolfo G. Cuevas6, David W. Wetter1, and Lorna H. McNeill1
Abstract Background: African Americans suffer disproportionately from the adverse consequences of behavioral risk factors for cancer relative to other ethnic groups. Recent studies have assessed how financial strain might uniquely contribute to engagement in modifiable behavioral risk factors for cancer, but not among African Americans. The current study examined associations between financial strain and modifiable cancer risk factors (smoking, at-risk alcohol use, overweight/obesity, insufficient physical activity, inadequate fruit and vegetable intake, and multiple risk factors) among 1,278 African American adults (age, 46.5 12.6 years; 77% female) and explored potential mediators (stress and depressive symptoms) of those associations. Methods: Logistic regression models were used to examine associations between financial strain and cancer risk factors. Analyses were adjusted for age, sex, partner status, income, educational level, and employment status. Analyses involving overweight/obesity status additionally controlled for fruit and vegetable intake and physical activity. Nonparametric bootstrapping procedures were used to assess mediation. Results: Greater financial strain was associated with greater odds of insufficient physical activity (P < 0.003) and smoking (P ¼ 0.005) and was positively associated with the total number of cancer risk factors (P < 0.0001). There was a significant indirect effect of both stress and depressive symptoms on the relations of financial strain with physical inactivity and multiple risk factors, respectively. Conclusions: Future interventions aimed at reducing cancer disparities should focus on African Americans experiencing higher financial strain while addressing their stress and depressive symptoms. Impact: Longitudinal studies are needed to assess the temporal and causal relations between financial strain and modifiable behavioral cancer risk factors among African Americans. Cancer Epidemiol Biomarkers Prev; 23(6); 967–75. 2014 AACR.
Introduction Cancer is a major public health problem in the United States (1). Although statistics indicate an approximate 20% decline in cancer death rates by the year 2009 from their peak in 1991 (1), considerable disparities still exist in terms of people benefiting from this falling trend. For instance, overall cancer incidence and death rates are higher among African American men than white men for every cancer site (1). Several factors are known to con-
Authors' Affiliations: Departments of 1Health Disparities Research and 2 Biostatistics, The University of Texas MD Anderson Cancer Center; 3 Department of Health Promotion and Behavioral Sciences, The University of Texas School of Public Health; 4Department of Educational Psychology, College of Education and 5Department of Psychology, College of Liberal Arts and Social Sciences, The University of Houston, Houston, Texas; and 6 Department of Psychology, College of Liberal Arts & Sciences, The Portland State University, Portland, Oregon Corresponding Author: Lorraine R. Reitzel, Health Program, Department of Educational Psychology, College of Education, University of Houston, 491 Farish Hall, Houston, TX 77204-5029. Phone: 713-743-6679; Fax: 713743-4996; E-mail: [email protected] doi: 10.1158/1055-9965.EPI-14-0016 2014 American Association for Cancer Research.
tribute toward an increased risk of cancer incidence and associated mortality among African American adults, including smoking, at-risk use of alcohol, being overweight or obese, insufficient physical activity, and inadequate fruit and vegetable intake (1–4). For example, African Americans tend to have higher prevalence of obesity and overweight-related diseases as compared with other racial/ethnic groups (5, 6). Unhealthy dietary habits and lower rates of physical activity have also been cited as contributing to their higher burden of chronic diseases relative to whites (6, 7). In addition, African American smokers are more susceptible to cancer than white smokers, and experience more difficulty quitting smoking (8, 9). Because reducing prevalence of these behavioral cancer risk factors among African Americans is an essential strategy to reduce overall cancer-related health disparities, research focused on better understanding of their specific determinants is needed. Socioeconomic status (SES) is a widely acknowledged social determinant of health and health-related behaviors. Markers of SES include an individual’s education, occupation, and income, which affect health insurance status and access to health services (2, 10, 11). Literature suggests
www.aacrjournals.org
Downloaded from cebp.aacrjournals.org on April 19, 2015. © 2014 American Association for Cancer Research.
967
Published OnlineFirst April 16, 2014; DOI: 10.1158/1055-9965.EPI-14-0016
Advani et al.
that individuals with lower SES experience worse health outcomes compared with those with higher SES (12, 13). Moreover, racial/ethnic disparities for major cancer sites, including colorectal, breast, and prostate, are largest in the lowest SES groups (14). Lower SES is also associated with a higher prevalence of several modifiable risk factors for cancer, including smoking (15), being overweight/obese (15, 16), lower rates of physical activity (17), and intake of unhealthy diet (15). Unfortunately, African Americans often tend to fall in the lower SES group, predisposing them to an increased risk of worse health outcomes relative to other ethnic groups (18). Recently, research on social determinants of health has gone beyond traditional indicators of SES to consider how more nuanced socioeconomic factors might affect health and health behaviors. One factor of interest is financial strain. Financial strain, also known as income inadequacy, represents an individual’s unfavorable subjective perception of their income to needs ratio (19), and although perhaps most relevant to those of lower SES can be applicable to individuals across the income spectrum. Literature suggests that financial strain is considered a better predictor of mortality than other SES indicators, particularly among African Americans (20). Financial strain is tied to increased unmet health needs and thus increased mortality among older African American adults (20). Likewise, financial strain has been linked to several modifiable cancer risk factors such as higher smoking rates (21–25), lower cessation rates (26), at-risk use of alcohol (22, 23, 25, 27, 28), obesity (29), and unhealthy dietary habits (25). However, limited studies have focused on these associations specifically in the context of the African American population. Furthermore, studies have shown that there are multiple pathways by which an individual’s financial status affects health behaviors (12). Financial strain is associated with psychosocial factors such as higher stress (22, 30) and depressive symptoms (30–34). On the other hand, stress and depression have been causally associated with unhealthy behaviors (35). These relations are also consistent with theoretical models suggesting that lower financial status might engender higher perceived stress and depressive symptoms, which contribute to unhealthy behaviors (12, 36). However, no studies to our knowledge have addressed potential indirect effects of stress and/or depressive symptoms on the association between financial strain and several cancer risk factors among a large sample of African American adults. The purpose of the current study was to examine the unique association of financial strain with several modifiable behavioral cancer risk factors (i.e., smoking, at-risk use of alcohol, being overweight/obese, insufficient physical activity and inadequate intake of fruits and vegetables) in a large sample of church-going African American adults. Because more than 50% of African American adults attend church on a weekly basis (37), and because church settings offer an acceptable and sustainable infrastructure for the delivery of interventions to affect
968
Cancer Epidemiol Biomarkers Prev; 23(6) June 2014
modifiable behavioral cancer risk factors (e.g., 38, 39), studies among African American church-goers are of particular interest. An exploratory aim of the current study was to assess whether significant associations between financial strain and cancer risk behaviors were attributable to stress and/or depressive symptoms. On the basis of the previous literature in this area, we hypothesized that greater financial strain would be associated with higher odds of engagement in behavioral cancer risk factors, and that stress and depressive symptoms would yield significant indirect effects in these associations.
Materials and Methods Participants and procedures Data were from the second year of a longitudinal cohort study focused on elucidating factors associated with cancer risk among African Americans. This was the first year that financial strain items were administered. Participants comprised a convenience sample recruited from a large church in Houston, Texas. Recruitment was accomplished through printed and televised media within the church and in-person solicitation. Individuals were eligible to participate if they were 18 years of age or older, resided in the Houston area, had a functional telephone number, and attended church. Participants (N ¼ 1,501) completed a computerized survey at the church during the first year of data collection, and were contacted a year later to participate for a second time. In total, 1,375 participants (91.6% of the original cohort) participated in the second year of data collection. Participants were compensated with a $30 gift card following the survey procedures. Only participants with complete data on the measures described below (N ¼ 1,278; 85.1% of the original cohort) were included in the current study. Data were collected between January and August 2010. Measures Sociodemographics. Sociodemographics included age, sex, partner status (married/living with partner or single/widowed/divorced), total annual household income (
